565850269-5-16-2023-29-AS-KLOZ-CRVSRA-20230516140602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850269
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:12:43 PM

Document Has Been Signed on 05/16/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KINDCARE SENIOR HOME		FACILITY NUMBER:	565850269
ADMINISTRATOR:	MARILOU ROJAS		FACILITY TYPE:	740
ADDRESS:	4810 JUSTIN WAY		TELEPHONE:	(323) 236-9397
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Marilou Rojas		TIME COMPLETED:	02:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Administrator Marilou Rojas and explained the reason for the inspection. When the LPA arrived there were two staff and six residents present. There are currently three residents receiving hospice care services. During the inspection, the LPA left the facility at 11:50 AM and returned at 1:39 PM to complete the inspection.

The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 9:42 AM. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 10:03 AM and operational at the time of the visit. There is one fire extinguisher fully charged and was last serviced 01/23/2023. The LPA observed required postings throughout the common space. The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use with a single-latched. No bodies of water noted. The facility has one common and one private restroom for client use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature in the common hallway restroom measured at 106 degrees F. The garage is where the washer and dryer are held, including additional perishable food items. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. Infection control practices were discussed. The facility has a sufficient supply of Personal Protective Equipment (PPE).

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KINDCARE SENIOR HOME	FACILITY NUMBER: 565850269
	VISIT DATE: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

BEDROOMS: The four resident bedrooms where furnished appropriately with with clean linens, appropriate furnishings, and sufficient lighting.

MEDICATIONS: Medications are locked and centrally stored in the living room. At 10:00 AM medications for three clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 10:36 AM record review for five clients and three staff was conducted. Resident and staff files reviewed were found to be complete. The Administrator's certificate expires in November 2023. Disaster drills are conducted quarterly, of which the last drill was conducted on 04/07/2023. At 11:24 AM staff and resident interviews were conducted.

No deficiencies were observed during the inspection. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2